Bridging a Cultural Divide: Cross-cultural Issues in Cancer Care

Bridging a Cultural Divide: Cross-cultural Issues in Cancer Care

ABSTRACT: This article is the last in a series focusing on ethical issues in cancer care, prepared by researchers at Northwestern University. The articles highlight selected ethical issues, place the issues in the context of relevant literature, and comment on their significance in oncology practice. These issues are discussed in greater depth in Ethical Issues in Cancer Care (Kluwer, 1999).

Nearly all health care providers in the United States
today care for at least some patients who come from a different cultural
background than their own. Accordingly, health care providers have become more
aware of cultural issues in the clinical setting. When it comes to the care of
cancer patients, cross-cultural issues are especially important.

Cancer patients, who are undergoing extreme emotional distress
as a result of their cancer diagnosis, must be able to clearly understand
diagnoses and treatment options, and make cooperative decisions about their
care. The provider, patient, and patient’s family must maintain constant and
open communication for the patient to understand these issues and take an
active role in treatment. For patients and providers who are from different
cultural backgrounds, this kind of communication can be challenging.

In his chapter, Dr. Chambers outlines the effect of cultural
issues on medical ethics and the need for health care providers to be attentive
and responsive to patients’ cultural backgrounds so as to effectively resolve
conflicts that may arise from differences in language, worldview, values, and
ethos. Dr. Chambers provides techniques that health care providers can use to
prevent and resolve such conflicts and ultimately improve the quality of
patient care.

Cross-cultural issues become especially important in light of
the disparities in cancer incidence and mortality among ethnic minorities in
the United States. Improving the quality of care for ethnic minorities may help
to alleviate these gross inequalities.[1] Providers have the potential to
drastically improve patient care for ethnic minorities by setting aside
commonly held stereotypes, familiarizing themselves with patients’ cultural
backgrounds, and becoming sensitive to cultural differences.

One of the first steps to improving patient care and preventing
and resolving cross-cultural conflicts is awareness of one’s own cultural
identity. As Dr. Chambers points out, health care providers who are members of
the majority population often assume that they themselves have no ethnic
identity, which can lead them to see their own beliefs as "self-evident
and natural."[2]

It is important to recognize the biases of one’s own cultural
beliefs and attitudes, and to be aware of the dangers of imposing those beliefs
and attitudes on others.[3] Developing the techniques and skills to communicate
well with patients from other cultures is ultimately rooted in this
self-awareness.[2]

In the clinical setting, providers often see cultural issues as
barriers that need to be overcome in order to obtain informed consent from
patients for procedures. Rather than perceiving culture differences as a kind
of intrusion into the clinical setting, culture can be viewed as a context
within which people live and make decisions.[2]

Dr. Chambers warns against the temptation to make assumptions
or predictions about behavior based on cultural identity. Knowledge and
familiarity with a particular culture, however, can provide understanding about
patients’ behavior, prevent misunderstandings and problems, and help the
provider and patient arrive at meaningful decisions
together.

With some effort on the part of the provider, patient care can
be dramatically improved, and, in the long run, precious time can be saved.[4]

Speaking the Patient’s Language

Patients are burdened with tremendous emotional distress when
they are diagnosed with cancer. This burden is multiplied for the patient who
does not speak the provider’s language or share his or her cultural
background.

Such patients may be unable to clearly communicate fears,
problems, and symptoms to the health care provider, and may not be able to
follow instructions and recommendations. In addition, the provider may not be
able to make an accurate assessment of an individual’s physical and mental
state.

In one case related by Maria Die Trill in her article,
"Cross-Cultural Differences in the Care of Patients with Cancer,"
psychiatric consultation was requested to address depression and
"histrionic" complaints of pain in a Hodgkin’s lymphoma patient.
Once the patient was evaluated in his own language, however, he was found to
have a central nervous system involvement of herpes.[4]

Even at times when it seems unnecessary, a third-party
translator can be employed to avoid common mistakes such as this. Dr. Chambers
points to the value of professional as opposed to nonprofessional translators.

Nonprofessional translators (ie, a volunteer or family member)
are more prone to mistranslation of biomedical concepts and omission of
critical details.

Professional translators are indispensable in understanding
symptoms, providing an accurate patient history,
communicating instructions about medications, and discussing diagnoses and
treatment options. A professional translator who is considered an active part
of the medical team may also be able to translate subtle cultural information
as well as words.[2]

Nonverbal Language

Nonverbal language can also be a barrier to communication
between patients and providers who do not share the same cultural background.

Body language varies widely among cultures. A touch on the
shoulder can be comforting and welcome to one person, while to another it may
seem like an invasive gesture.[2] Lack of eye contact may sometimes be
interpreted as a sign of depression, disinterest, or inattention, although it
may be intended as a sign of respect.

Perceptions of comfort with regard to physical distance between
persons also varies from culture to culture. To assess the desired physical
distance between persons, providers may look for nonverbal cues when meeting
with new patients and follow their lead.[3]

Ethos, or "the character of our daily lives," as Dr.
Chambers puts it, is another source of cultural differences that health care
providers may experience. For instance, issues of individual patient autonomy
may differ among patients. Some patients may come from a more group-oriented
culture and view the family as an extremely vital aspect of their cancer care.

Providers may inquire of their patients if someone in the
household is consulted in decisions about health and whether the patient would
prefer to have that person present during medical visits.[3] Involving the
family can be a powerful way to alleviate some of the stress and pressure
patients feel when making important cancer treatment decisions.[4]

According to certain cultural beliefs, illness can be
attributed to both natural and supernatural causes, and these cultures tend to
emphasize the spiritual aspect of illness.[2] It may be tempting to discount
the significance of patients’ spiritual beliefs. In many cases, however,
these beliefs can be a powerful tool for helping patients and their families
cope with a cancer diagnosis and potential end-of-life issues.[5]

Respect for different languages, values, worldviews, and ethos
can bring the health care provider a greater understanding of individual
patients. By examining their own cultural biases and learning about the
influences of cultural beliefs on patients, health care professionals can open
new lines of communication that will benefit both themselves and their
patients.

"Development of communication skills should start from
personal conviction and effort," Maria Die Trill wrote in her article
about cross-cultural differences. "Our patients are our best teachers,
and sometimes what we learn from them is more than the help we can give them.
It is our responsibility to take advantage of our professional experience to
improve the overall medical support they deserve."[4]

References

1. Institute of Medicine: Committee on Cancer Research Among
Minorities and the Medically Underserved: The Unequal Burden of Cancer.
Washington, National Academy Press, 1999.